The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Weigh the client and report any weight gain.

Reporting any client complaints of pain or discomfort.

Evaluate the client for sleep disturbances.

Note and report the client's food and liquid intake during meals and snacks.

Assess the client for weakness and fatigue.

Answer and Explanation

Correct Answer : A,B,D

A)   Correct- Weighing the client and reporting any weight gain is a routine measurement that can be safely performed by the UAP. Weight gain can be an important indicator of fluid retention, a common issue in Cushing's syndrome.
B)   Correct- Reporting any client complaints of pain or discomfort is important for monitoring the client's well-being and promptly addressing any potential issues.
C)   Incorrect- Evaluating the client for sleep disturbances involves assessing the client's sleep patterns, quality, and potential disruptions. This requires nursing judgment and a deeper understanding of the client's condition and potential contributing factors, so it's not appropriate to delegate this task to the UAP.
D)   Correct- Noting and reporting the client's food and liquid intake during meals and snacks is part of monitoring the client's nutritional status, which is an appropriate task for the UAP.
E)   Incorrect- Assessing the client for weakness and fatigue involves a more comprehensive evaluation of the client's physical and physiological status, which requires nursing expertise. The nurse should directly assess and interpret these symptoms in the context of Cushing's syndrome to provide appropriate interventions.

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Correct Answer is A

Explanation

The client's history of lung cancer, persistent hoarseness, chronic cough, and labored respirations when speaking indicate potential respiratory complications. Coarse breath sounds may suggest the presence of airway obstruction or fluid accumulation in the lungs, which can be indicative of a worsening condition.

The nurse should intervene promptly by assessing the client's respiratory status further, providing appropriate respiratory support, and notifying the healthcare provider for further evaluation and intervention.

A. Inspect skin for redness. B. Use a residual limb shrinker. C. Avoid range of motion exercises. D. Apply alcohol to the residual limb after bathing.

Correct Answer is ["A","B"]

Explanation

The correct answer is a. Inspect skin for redness and b. Use a residual limb shrinker.

Choice A rationale:

Inspecting the skin for redness is crucial to identify any signs of infection or pressure sores early. Redness can indicate irritation or the beginning of a pressure ulcer, which needs to be addressed promptly to prevent further complications.

Choice B rationale:

Using a residual limb shrinker helps to reduce swelling and shape the residual limb for prosthetic fitting. It also helps in managing pain and promoting healing by providing consistent compression.

Choice C rationale:

Avoiding range of motion exercises is incorrect. Range of motion exercises are essential to maintain joint flexibility and prevent contractures, which can hinder the use of a prosthetic limb.

Choice D rationale:

Applying alcohol to the residual limb after bathing is not recommended. Alcohol can dry out the skin and cause irritation, which can lead to skin breakdown and infection. Instead, the residual limb should be kept clean and moisturized with appropriate skin care products.

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The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of lung cancer reluctantly comes to the clinic because of persistent hoarseness and a chronic cough. The client's respirations are labored when speaking and the capillary refill is 3 seconds. Which additional finding warrants intervention by the nurse?

Correct Answer is A

Explanation

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendation(s) should the nurse provide this client? (Select all that apply.)

Correct Answer is ["A","B"]

Explanation

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